Cash for Kidneys: The Case for a Market for Organs

There is a clear remedy for the growing shortage of organ donors, say Gary S. Becker and Julio J. Elias

By

Gary S. Becker and

Julio J. Elias

Updated Jan. 18, 2014 4:58 p.m. ET

In 2012, 95,000 American men, women and children were on the waiting list for new kidneys, the most commonly transplanted organ. Yet only about 16,500 kidney transplant operations were performed that year. Taking into account the number of people who die while waiting for a transplant, this implies an average wait of 4.5 years for a kidney transplant in the U.S.

ENLARGE

Getty Images

The situation is far worse than it was just a decade ago, when nearly 54,000 people were on the waiting list, with an average wait of 2.9 years. For all the recent attention devoted to the health-care overhaul, the long and growing waiting times for tens of thousands of individuals who badly need organ transplants hasn't been addressed.

Finding a way to increase the supply of organs would reduce wait times and deaths, and it would greatly ease the suffering that many sick individuals now endure while they hope for a transplant. The most effective change, we believe, would be to provide compensation to people who give their organs—that is, we recommend establishing a market for organs.

Organ transplants are one of the extraordinary developments of modern science. They began in 1954 with a kidney transplant performed at Brigham & Women's hospital in Boston. But the practice only took off in the 1970s with the development of immunosuppressive drugs that could prevent the rejection of transplanted organs. Since then, the number of kidney and other organ transplants has grown rapidly, but not nearly as rapidly as the growth in the number of people with defective organs who need transplants. The result has been longer and longer delays to receive organs.

Many of those waiting for kidneys are on dialysis, and life expectancy while on dialysis isn't long. For example, people age 45 to 49 live, on average, eight additional years if they remain on dialysis, but they live an additional 23 years if they get a kidney transplant. That is why in 2012, almost 4,500 persons died while waiting for kidney transplants. Although some of those waiting would have died anyway, the great majority died because they were unable to replace their defective kidneys quickly enough.

ENLARGE

The toll on those waiting for kidneys and on their families is enormous, from both greatly reduced life expectancy and the many hardships of being on dialysis. Most of those on dialysis cannot work, and the annual cost of dialysis averages about $80,000. The total cost over the average 4.5-year waiting period before receiving a kidney transplant is $350,000, which is much larger than the $150,000 cost of the transplant itself.

Individuals can live a normal life with only one kidney, so about 34% of all kidneys used in transplants come from live donors. The majority of transplant kidneys come from parents, children, siblings and other relatives of those who need transplants. The rest come from individuals who want to help those in need of transplants.

In recent years, kidney exchanges—in which pairs of living would-be donors and recipients who prove incompatible look for another pair or pairs of donors and recipients who would be compatible for transplants, cutting their wait time—have become more widespread. Although these exchanges have grown rapidly in the U.S. since 2005, they still account for only 9% of live donations and just 3% of all kidney donations, including after-death donations. The relatively minor role of exchanges in total donations isn't an accident, because exchanges are really a form of barter, and barter is always an inefficient way to arrange transactions.

Exhortations and other efforts to encourage more organ donations have failed to significantly close the large gap between supply and demand. For example, some countries use an implied consent approach, in which organs from cadavers are assumed to be available for transplant unless, before death, individuals indicate that they don't want their organs to be used. (The U.S. continues to use informed consent, requiring people to make an active declaration of their wish to donate.) In our own highly preliminary study of a few countries—Argentina, Austria, Brazil, Chile and Denmark—that have made the shift to implied consent from informed consent or vice versa, we found that the switch didn't lead to consistent changes in the number of transplant surgeries.

ENLARGE

A surgeon stands next to a monitor showing a donor kidney in 2012. The average cost of a kidney transplant is $150,000. Annual cost of dialysis: $80,000
Reuters

Other studies have found more positive effects from switching to implied consent, but none of the effects would be large enough to eliminate the sizable shortfall in the supply of organs in the U.S. That shortfall isn't just an American problem. It exists in most other countries as well, even when they use different methods to procure organs and have different cultures and traditions.

Paying donors for their organs would finally eliminate the supply-demand gap. In particular, sufficient payment to kidney donors would increase the supply of kidneys by a large percentage, without greatly increasing the total cost of a kidney transplant.

We have estimated how much individuals would need to be paid for kidneys to be willing to sell them for transplants. These estimates take account of the slight risk to donors from transplant surgery, the number of weeks of work lost during the surgery and recovery periods, and the small risk of reduction in the quality of life.

Our conclusion is that a very large number of both live and cadaveric kidney donations would be available by paying about $15,000 for each kidney. That estimate isn't exact, and the true cost could be as high as $25,000 or as low as $5,000—but even the high estimate wouldn't increase the total cost of kidney transplants by a large percentage.

Few countries have ever allowed the open purchase and sale of organs, but Iran permits the sale of kidneys by living donors. Scattered and incomplete evidence from Iran indicates that the price of kidneys there is about $4,000 and that waiting times to get kidneys have been largely eliminated. Since Iran's per capita income is one-quarter of that of the U.S., this evidence supports our $15,000 estimate. Other countries are also starting to think along these lines: Singapore and Australia have recently introduced limited payments to live donors that compensate mainly for time lost from work.

Since the number of kidneys available at a reasonable price would be far more than needed to close the gap between the demand and supply of kidneys, there would no longer be any significant waiting time to get a kidney transplant. The number of people on dialysis would decline dramatically, and deaths due to long waits for a transplant would essentially disappear.

ENLARGE

Today, finding a compatible kidney isn't easy. There are four basic blood types, and tissue matching is complex and involves the combination of six proteins. Blood and tissue type determine the chance that a kidney will help a recipient in the long run. But the sale of organs would result in a large supply of most kidney types, and with large numbers of kidneys available, transplant surgeries could be arranged to suit the health of recipients (and donors) because surgeons would be confident that compatible kidneys would be available.

The system that we're proposing would include payment to individuals who agree that their organs can be used after they die. This is important because transplants for heart and lungs and most liver transplants only use organs from the deceased. Under a new system, individuals would sell their organs "forward" (that is, for future use), with payment going to their heirs after their organs are harvested. Relatives sometimes refuse to have organs used even when a deceased family member has explicitly requested it, and they would be more inclined to honor such wishes if they received substantial compensation for their assent.

The idea of paying organ donors has met with strong opposition from some (but not all) transplant surgeons and other doctors, as well as various academics, political leaders and others. Critics have claimed that paying for organs would be ineffective, that payment would be immoral because it involves the sale of body parts and that the main donors would be the desperate poor, who could come to regret their decision. In short, critics believe that monetary payments for organs would be repugnant.

But the claim that payments would be ineffective in eliminating the shortage of organs isn't consistent with what we know about the supply of other parts of the body for medical use. For example, the U.S. allows market-determined payments to surrogate mothers—and surrogacy takes time, involves great discomfort and is somewhat risky. Yet in the U.S., the average payment to a surrogate mother is only about $20,000.

Another illuminating example is the all-volunteer U.S. military. Critics once asserted that it wouldn't be possible to get enough capable volunteers by offering them only reasonable pay, especially in wartime. But the all-volunteer force has worked well in the U.S., even during wars, and the cost of these recruits hasn't been excessive.

Whether paying donors is immoral because it involves the sale of organs is a much more subjective matter, but we question this assertion, given the very serious problems with the present system. Any claim about the supposed immorality of organ sales should be weighed against the morality of preventing thousands of deaths each year and improving the quality of life of those waiting for organs. How can paying for organs to increase their supply be more immoral than the injustice of the present system?

Under the type of system we propose, safeguards could be created against impulsive behavior or exploitation. For example, to reduce the likelihood of rash donations, a period of three months or longer could be required before someone would be allowed to donate their kidneys or other organs. This would give donors a chance to re-evaluate their decisions, and they could change their minds at any time before the surgery. They could also receive guidance from counselors on the wisdom of these decisions.

Though the poor would be more likely to sell their kidneys and other organs, they also suffer more than others from the current scarcity. Today, the rich often don't wait as long as others for organs since some of them go to countries such as India, where they can arrange for transplants in the underground medical sector, and others (such as the late
Steve Jobs
) manage to jump the queue by having residence in several states or other means. The sale of organs would make them more available to the poor, and Medicaid could help pay for the added cost of transplant surgery.

The altruistic giving of organs might decline with an open market, since the incentive to give organs to a relative, friend or anyone else would be weaker when organs are readily available to buy. On the other hand, the altruistic giving of money to those in need of organs could increase to help them pay for the cost of organ transplants.

Paying for organs would lead to more transplants—and thereby, perhaps, to a large increase in the overall medical costs of transplantation. But it would save the cost of dialysis for people waiting for kidney transplants and other costs to individuals waiting for other organs. More important, it would prevent thousands of deaths and improve the quality of life among those who now must wait years before getting the organs they need.

Initially, a market in the purchase and sale of organs would seem strange, and many might continue to consider that market "repugnant." Over time, however, the sale of organs would grow to be accepted, just as the voluntary military now has widespread support.

Eventually, the advantages of allowing payment for organs would become obvious. At that point, people will wonder why it took so long to adopt such an obvious and sensible solution to the shortage of organs for transplant.

Mr. Becker is a Nobel Prize-winning professor of economics at the University of Chicago and a senior fellow at the Hoover Institution. Mr. Elias is an economics professor at the Universidad del CEMA in Argentina.

gud day to you my name is noli,i am a filipino my blood type is B,i stay here in the philippines,i am willing to be a kidney donor but in exchange of money,for about 500,000usDOLLAR.FOR so if theres someone rich individual in need of a kidney donor,just email me at:methusela777777@yahoo.com....GODBLESS

There is real downside for the poor if not managed above board. Just think of the temptation and money that exists in black market organs supplied by free-will and even kidnapped poor people. Academic economists must realize the efficiency of two kidneys from one person on occasion will flow freely in our globally connected world. The greater common good theory does not work for me if just one more person is victimized in free trade organs.

There is already a problem with the trafficking of unwilling victims for the purposes of sex. Young males and females are both kidnapped and sold into slavery their bodies to be sold repeatedly to the highest bidder. What makes you think the same scenario will not play out when organs are involved ? It is only a matter of time until an unscrupulous group begins scooping up victims , resecting an organ or two and then leaving the " donor" to die in a dumpster or a bathtub full of ice. I think the professor of economics needs to do a bit more research on this one. I think a " black market " for these organs already exists and you would simply be facilitating the worst of all Orwellian societies.

"Scattered and incomplete evidence from Iran indicates that the price of kidneys there is about $4,000 and that waiting times to get kidneys have been largely eliminated."

in my opinion, the whole article should have been about iran's market. why speculate about what could happen when we can see what is happening? surely, some people inside and outside of iran are willing to make the evidence less incomplete....

"Relatives sometimes refuse to have organs used even when a deceased family member has explicitly requested it, and they would be more inclined to honor such wishes if they received substantial compensation for their assent. "

again, speculation. you know, not everyone thinks like an economist. maybe they would be more willing to honor such wishes if they were legally binding (to the state or medical community)? on the other hand, not everyone thinks like a lawyer either.

Many years ago, I was asking the same question of my attorney while in the process of updating my Will.My attorney suggested the darker side of selling organs for profit - that while some may freely elect to do so, the potential of organs being harvested against a person's will are very real. My first thought was that he was being more than a little dramatic.However, I have since reconsidered my thoughts on the matter.I am for a free market, and at the same time, my moral compass and life experience tells me that selling organs is a bad idea - an idea that would take advantage of the world's disadvantaged."Let people make up their own minds, and control their own lives!" Some might say."Yes", and what if they are not of sound mind, the free will to make this decision for themselves, or too desperate to know better?I have lived in a third-world country, and seen how rough life can be for many / most of these people.How tempting this kind of money would be for them.I would not want to have any hand in creating a market that encourages people to get into the business of organ farming - or whatever you will call it.Selling organs to save and enrich everybody's life seems like a really great idea until we consider the negative potential, which I believe would fast become a grave reality.

What's more unjust than dying while waiting for a kidney, is 95% of income gains since the 1970's going to the top fraction of a percent, while incomes of the bottom quintile decline, and the most desperate having to sell their organs for a paltry $25K in order to survive.

The reason that I will not donate my organs is just as was cited in this article. I refuse to have some rich person skew the system and take an organ to which they are not entitled. The rich get enough. Death is one of the few equities of this life. If you want more people like me to donate organs. "Guarantee" me that one of my middle class or poor brothers and sisters would get equal access to the organ. Until you can guarantee that, I will take them with me to the grave. You can manipulate my wages, outsource my job but thank goodness you can't "take" my body parts. I will take them to the grave before I will have the rich manipulate that.

While I do like this idea..I wonder if down the road it would lead to a more severe shortage. For example, if say youth are compelled to sell their kidney so they can pay for college, yet down the road they get a disease affecting the other kidney; equaled out down the line with most only having one kidney as they sold it to those sick prior..the shortage continues. Indeed it would go global the legal sale of organs and would take a bit longer to plateau.

That said, I think the key is growing organs and printing them out (as shown in various TED Talks and academic journals.) It's maybe 10-15 years from actual mainstreaming..it will become the real solution to all of this. That said, I'd be ok with organ sale as long as it was taxed in order to R&D in the areas of organ growing and other medical areas that need the funding. A renewed shortage of organs as my first fear would be probably then wouldn't occur as we push for the development of a workable model of organ growing. Even without the tax revenues for grants awarded or tax cuts for innovations, I think organ growing is on its way with or without the government help. All the government has to do is not be stupid about regulating it too much.

Lastly...thinking of the shortage..this really does provide a weak point in which those who are against the individual mandate of ACA to strike back in protest by changing themselves from organ donor to non-organ donors and making it known that the actions are in protest to the individual mandate of ACA. Stress the system out enough..it may be possible to force the government's hand on the issue. Maybe..they may just require everyone be organ donors without the opt-out choice.

Pure Capitalism for body parts? Of course the WSJ would say "yes". No "regulations that stifle the market" right? If the Democrats would just "get out of the way" the economy for organs would thrive, right? Sound familiar? Tell that to the 700 million rat-eating, ultra-poor in India. Or the utterly destitute in Somalia or Afghanistan. Sure, they can spare a kidney; let the market set a price for their bodies. Heck, there are enough people on Earth living on less than $1000 a year that putting $10K in front of them they'd give up an eye, an ear, and maybe even a limb for that amount of money. Let the market decide indeed...

"Living donation makes a significant contribution to kidney (and to a lesser extent liver) transplantation programmes worldwide and carries a number of advantages. Transplantation becomes elective and can be scheduled to the time the patient needs the transplant. Furthermore, the outcomes are better than if a deceased donor organ is used. However, this is at a cost. The mortality rate for living kidney donors is ~1:3–5000, while for living liver donors, it may be as high as 1:200. Morbidity occurs in 10–15% of patients and there are the added social and possibly financial costs to the donor. Living donation also opens the opportunity to commercialization and trafficking..."

Later it comments on the commercialization and trafficking in organs,

"Payment for organs and transplant tourism

In 2004, the World Health Assembly (WHA) adopted a resolution that urged member states ‘to take measures to protect the poorest and vulnerable groups from transplant tourism and the sale of tissues and organs, including attention to the wider problem of international trafficking in human tissues and organs’. As of 2007, the WHO estimated that 10% of organ transplants performed worldwide involved these unacceptable activities.

To address the concerns of the WHA and the growing problem of organ sales, a Summit Meeting of more than 150 international representatives of scientific and medical bodies, government officials, social scientists, and ethicists was held in Istanbul, Turkey, from April 30 to May 2, 2008. The result of these deliberations was the Istanbul Declaration on Organ Trafficking and Transplant Tourism. The Declaration of Istanbul calls for a prohibition of organ trafficking, transplant commercialism, and transplant tourism: ‘because transplant commercialism or the buying and selling of organs targets impoverished and otherwise vulnerable donors it inexorably leads to inequity and injustice and should be prohibited. The vulnerable donors are minors, illiterate and impoverished persons, undocumented immigrants, prisoners, and political or economic refugees’"

WSJ would do a service if it would invite legitimate rebuttals. debate, or even agreement -- but a diverse selection of points of view. Invite at least a selection of physicians and transplant surgeons and ethicists.

My problem with organ the donation business is that the doctors and recipients seem to think they have a right to MY body parts. The Guy Upstairs sent me here with a full set. I think I'll keep them. I may even take them with me. As long as someone else thinks I have no right to do that, I'll fight to keep them.

If you ever need an organ for a transplant operation, chances are you will die before you get one. You can improve your odds by joining LifeSharers. Membership is free.

LifeSharers is a non-profit national network of organ donors. LifeSharers members promise to donate upon their death, and they give fellow members first access to their organs. As a LifeSharers member, you will have access to organs that otherwise may not be available to you. As the LifeSharers network grows, more and more organs may become available to you -- if you are a member.

From what I see of the future of our healthcare, this might be a good idea. In a free market, the deal is between you and the seller with no government intervention. Under obamacare, a bureaucrat will decide who is viable and who is not ...or who is "productive" and who is not and will grant or withhold the the treatment accordingly.I do see the problems with the idea but as always, we can work those out among ourselves without the "help" of an over reaching government.

The problem can be solved by making the donation of organs automatic with an opt out on driver's licenses. Opt out rather than opt in. Germany has an opt-in system, and has an organ donation consent rate of 12% a while uses an opt-out system and has a consent rate of 99.98%.

This is one of the hypocrisies of health care I just love: you can donate all you want while "providers" (usually physicians) charge all they want. Only in health care. My Wife donates platelets at the local Children's Hospital, they charge thousands for the processing and transfer -- she gets to deduct her mileage expenses on our taxes, yet, loses a work day making the multi-hour donation. You can make more money selling your blood in 15 minutes than doing this. Obviously, she does it for a child, usually fighting leukemia, whom she never meets and this is one of many reason why I just have to love her. But there is still a touch of a fraud element to the whole "donation" thing that the health community ignores.

This is a bad idea on so many levels. But my main concern is that with profit always driving all aspects of American business, it would be a very short time period before this whole process was hijacked and then abused by the private sector. Business ethics is the most amazing oxymoron since military intelligence and that means that if you can buy an organ, then you can sell to the highest bidder. And we also know the one and only rule in American business today is, "Don't get caught." No, leave the system alone and let's go with truly socialized medicine instead of the current system that lobbyists and big pharma has forced us into.

WOW! Human arrogance and greed have indeed no limits.I am supposed to give up an organ-that nature was clever enough to build in twice in our biological design,so that if something goes wrong you have an 'insurrance' policy-for 5 000 to 15 000 $! Someone gets an LIFE extension and I am going to get less cash than people who live on social security get in 1 Year! If the WSJ is such a fan of the free market-let the market decide! Let see how many people will sell their organs-if there are more than 100 000-good news for the people needing transplants(and the WSJ obviously)...if the number is less-tough luck-I or the donors, control the price and that price is going to be much,much higher than 15 000 $.

Interesting logic here-even more interesting dollar figure; $15,000 for a kidney buys 15 or more years of life over dialysis! Why not let the market place decide by setting up an auction market? Surely the billionaire who wants a kidney values his life at more than a $1000 a year. Where is our society going?

I realize liberals think all rich people just woke up one morning to find $25 million under their pillow, but it is possible that just a few made their money working 60 hour weeks for decades. ( I would be an example of the latter ). Given that, a mutually agreed to exchange of money for organs seems quite practical as long as the donor can survive without the organ in question.

Perhaps we could induce comas on the severely mentally I'll and keep them around for parts. Solves two problems at once and nobody gives a carp about them anyway.

Perhaps instead of abortion, we could harvest the fetuses at 25 weeks and keep them in a box until they're large enough to provide useful parts. Nobody cares about them either and they might as well provide some utility to society. Why waste a good human?

Why not kill off granny when she hits 65 and grab her organs too? Again, solves two problems at once.

Might as well harvest organs from low IQ kids too. We would get much needed organs for suffering children and reduce the number of progressives too. Another twofer.

Today, with the scarcity of "replacement parts", you create some jeopardy for yourself to donate a kidney. If the market operates successfully, you would not have your own "spare", but would have significantly better access should you have a need.

Various transplant centers have differing age standards- many of which are waivable depending upon the health of the donor. As a practical matter, older people oftentimes are not good candidates because of pre-existing health issues which either makes the procedure for the donor too risky or the organ to be donated significantly less than optimal. Having said that, I am aware of a couple instances in which people in their early 70's have donated.

I hope you are not presuming me to be a liberal because I dare point out a rather common sense limitation of Capitalism.

Congratualtions on your hard work and success but I don't think that gives you the moral right to take advantage of another human being and as I said, use the poor for your spare parts.

I am assuming you earned your money virtuously and thus will be prepared to meet your maker on His timing and without having to explain how you took advantage of a poor person to extend your life by a few years.

This copy is for your personal, non-commercial use only. Distribution and use of this material are governed by our Subscriber Agreement and by copyright law. For non-personal use or to order multiple copies, please contact Dow Jones Reprints at 1-800-843-0008 or visit www.djreprints.com.